Achalasia
Differential diagnosis
 Pseudoachalasia
 Esophageal dysmotility
 Esophageal spasm – simultaneous frequent contractions, however normal LES relaxation. Patients complain
more often of chest pain. Surgery not indicated.
 Peptic stricture – benign vs malignant
 Diverticulum – Zenker, epiphrenic
 Chaga’s disease – identical to achalasia,caused by parasite Trypanosoma cruzi.
Workup
 Barium swallow – esophageal dilation, bird’s beak
 EGD – dilation, tapering, presence of food. Absence of mass or stricture.
 Manometry – Three different types of achalasia. Aperistaltic esophagus w/ incomplete or absent LES relaxation.
 CXR can be suggestive with dilated esophagus, absence of gastric bubble.
 CT may be useful to rule out extrinsic compression
Discussion
 Primary esophageal disorder, no known etiology
 1/100,000, between ages 20-50 usually
 Neuronal degeneration
Treatment
 Calcium channel blockers, nitrates cause SM relaxation. Short lived, significant side effects. Temporizing agents
and for poor surgical candidates
 Botox – endoscopic injection. Improves dysphagia, lasts < 6 months. Causes inflammatory reaction, makes
myotomy difficult. Reserve for poor surgical candidates.
 Pneumatic dilatation – 60-75% success first try, 85% repeat dilatation. 3-5% perforation rate. Alternative for
patients unable to undergo lap myotomy.
 Heller myotomy – treatment of choice, especially < 40 years old. Relieves symptoms in 90% of patients. Low
morbidity (6.3%) and mortality (0.1%). Perform a partial fundoplication (Dor or Toupet), decreases GERD from
31.5% to 8.8%. If persistent symptoms and suspicion of incomplete myotomy, repeat myotomy.
 POEM – comparable success rates to myotomy, not time tested, still limited literature.
 Transhiatal Esophagectomy – for persistent symptoms w/ complete myotomy, megaesophagus or sigmoid
esophagus.
Surgical approach
 Clear liquid diet x 2 days, decompress with NG prior to anesthesia! Supine, supra-umbilical camera port, 4
additional ports (2 working ports in epigastrium, 1 for liver retraction and one in left abdomen for stomach
retraction). Open gastrohepatic ligament, clean anterior aspect of esophagus, remove gastroesophageal fat
pad. Protect anterior vagus nerve. Using hook cautery, start myotomy above GE junction. Go 6 cm above GEJ,
2 cm down onto stomach, through longitudinal and circular layers. Bluntly separate edges of myotomy for half

of esophageal circumference. EGD insufflation to check mucosal integrity with stomach under water. Perform
Dor or Toupet.
If intraop mucosal injury identified – safe board answer, close mucosa with absorbable sutures, close myotomy,
perform myotomy on opposite aspect of esophagus.
Postop management
 POD 1 esophagram
 Start clear liquid diet, advance as outpatient over weeks
 40-50% will have recurrent dysphagia, heartburn, regurgitation, usually responsive to PPI or dietary
modifications.